Project Summary Abstract There is growing recognition that acute hospitalization contributes to marked functional decline in older Veteran populations. Nearly 20% of all hospitalized older adults are discharged to a skilled nursing facility (SNF) to address these functional deficits. Unfortunately, rehabilitation in SNFs does not adequately restore physical function, which directly contributes to poor community discharge rates. Strikingly, only 27.8% of all patients admitted to SNFs are discharged to a community setting, which suggests a paradigm shift is required to optimize rehabilitation within SNFs. Currently, usual care rehabilitation in SNFs consists of low-intensity rehabilitation interventions, which are physiologically inadequate to induce meaningful changes in skeletal muscle strength and physical function. Therefore, we propose a novel IntenSive Therapeutic Rehabilitation for Older skilled NursinG HomE Residents (I-STRONGER) program, which integrates principles of physiologic tissue overload into combined strengthening and functional interventions for greater gains in physical function. The overall goals of this investigation are to 1) demonstrate feasibility of I-STRONGER in SNF settings and 2) determine the effectiveness of I-STRONGER in improving physical function. A comparison of usual care (UC) with I-STRONGER will occur using a staged, 2 group design (independent cohorts), with a single SNF serving as its own control. The first cohort of SNF patients will participate in UC (Stage 1) and after therapist training on I-STRONGER is completed, a second cohort of patients entering the same facility will participate in I-STRONGER (Stage 2). The feasibility of I-STRONGER will be evaluated by patient acceptability and therapist compliance measures. Functional outcomes will be evaluated at admission and discharge including: Short Physical Performance Battery, Timed-Up-and- Go, gait speed and Barthel Index.